When turning a male client who has been lying on his back for 2 hours, the nurse notes that the skin over his sacrum is very white. The client is repositioned and when the nurse reassesses the sacrum 2 hours later, the area is bright red. Which intervention should the nurse implement?

Apply a warm compress to the sacral area.

Wash the area with soap and water.

Reassess and turn the client in 30 minutes.

Massage the reddened area with lotion.

Answer and Explanation

The Correct Answer is C

A. Applying a warm compress does not address the prevention of pressure ulcers and could potentially exacerbate skin issues. The primary focus should be on preventing further pressure.
B. Washing the area with soap and water does not effectively address the issue of pressure ulcer risk or the need for repositioning to alleviate pressure.
C. Reassessing and turning the client every 30 minutes helps prevent the development of pressure ulcers by relieving pressure on vulnerable areas, which is crucial for maintaining skin integrity.
D. Massaging the reddened area can cause further damage and is not recommended. Proper repositioning and pressure relief are the appropriate interventions.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

A. The use of "2.0 mg" is incorrect because trailing zeros can lead to dosage errors. The correct documentation should avoid trailing zeros to prevent misinterpretation.
B. "Morphine 2 mg IV every 4 hr PRN for severe pain" is the correct format. It uses the full name of the drug, avoids abbreviations that could be confused, and follows best practices for documenting as-needed (PRN) medications.
C. Using "MS" instead of "morphine" is not recommended because "MS" can be confused with magnesium sulfate or other medications. The full drug name should always be used.
D. Similar to option A, the use of "2.0 mg" includes a trailing zero, which should be avoided to reduce the risk of errors in medication administration.

A. Position the client in a lateral lying position. B. Document the blood pressure and monitor the client. C. Encourage an increase in oral fluid intake. D. Hold the medication and notify the healthcare provider.

Correct Answer is D

Explanation

A. Positioning the client in a lateral lying position might help with comfort but does not address the immediate concern of the low blood pressure.
B. Documenting the blood pressure and monitoring the client is important, but it does not address the need to prevent potential adverse effects from administering the medication at such a low blood pressure.
C. Encouraging an increase in oral fluid intake may be helpful in managing blood pressure, but the immediate priority should be to address the potential effects of the medication on the low blood pressure.
D. Holding the medication and notifying the healthcare provider is the appropriate action because administering the medication with a blood pressure of 80/50 mm Hg could worsen hypotension and lead to further complications. The healthcare provider should be informed to reassess the medication plan.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

When turning a male client who has been lying on his back for 2 hours, the nurse notes that the skin over his sacrum is very white. The client is repositioned and when the nurse reassesses the sacrum 2 hours later, the area is bright red. Which intervention should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The healthcare provider gives a verbal prescription for 2 mg of intravenous morphine to be given to a client every 4 hours as needed for severe pain. How should the nurse document the prescription?

Correct Answer is B

Explanation

The healthcare provider prescribes two doses of an antihypertensive medication for a client. Before administering the second dose, the nurse obtains a blood pressure measurement of 80/50 mm Hg. Which action should the nurse take?

Correct Answer is D

Explanation

In-home hospice care is arranged for a client with stage 4 lung cancer. While the palliative care nurse is arranging for discharge, the client verbalizes concerns about pain. Which action should the nurse implement?

To assess a client's dorsalis pedis pulse, the nurse applies firm pressure over the top of the foot between the extension tendons of the great and first toes, but does not feel a pulsation. Which action should the nurse take next?

A client, who speaks very little English, is being seen in the emergency department following an automobile accident. The client's sibling offers to act as an interpreter and asks about the laboratory results. Which response is best for the nurse to provide?

A female client who is receiving hospice care in her home expresses fear that dying will be painful. Which action should the nurse take first?

A client is requesting medicine for pain 30 minutes after receiving morphine sulfate 5 mg intravenously. Which intervention should the nurse implement next?

While electronically scanning the client's armband at the bedside prior to administering pain medication, the nurse observes the power flickers and the computer screen goes blank. The computer fails to reboot and the screen remains dark. Which action should the nurse do first?